A Conversation with Peter I. Juhn, M.D.

The executive director of Kaiser's Care Management Institute says guidelines have a place in every HMO, but there's more to care than that.

October 1, 1998

Medical roots run deep in the man who is leading the transformation of medical care delivery at the nation's largest HMO. Both of Peter Juhn's parents and a grandfather preceded him in the medical profession. Today, as executive director of Kaiser Permanente's Care Management Institute in Oakland, Calif., Juhn is responsible for developing systematic approaches to the management of major health conditions, along with tools to help Kaiser's 10,000 physicians adopt and use those approaches. So far, the institute has focused on diabetes, asthma, depression and cardiac conditions, using data-based measures. Juhn's responsibilities also include strategic assessment of the next generation of clinical data and information systems, including interactive telecommunications and telemedicine systems.

Juhn has an M.D. from Harvard University, a master's in Public Health from the University of Washington, and completed his residency at the Hospital of the University of Pennsylvania. He is board certified in internal medicine. Prior to joining Kaiser, Juhn was a senior fellow in the Robert Wood Johnson Clinical Scholars Program at the University of Washington. Juhn spoke recently with Senior Contributing Editor Patrick Mullen.

MANAGED CARE: Physicians face an enormous amount of new clinical information that is being created all the time. How do you help doctors cut through that?

PETER I. JUHN, M.D., M.P.H.: Through care management. One of our principles is to synthesize knowledge. Our approach to care is stated in [the Care Management Institute's] mission statement. CMI will, on a national level, synthesize knowledge about the best clinical approach and create, implement, and evaluate effective and efficient health care. The idea here is to take what's best about what we do internally, but also scan the external world to see what's best. We then put that together and bring it to physicians so that they don't have to read the 20,000 journals published monthly.

MC: Why should a Kaiser family physician in Atlanta trust you? What makes this a credible operation to do that distillation?

JUHN: We're credible because we rely upon the 10,000 Kaiser doctors to help create this for us. It's not a bunch of experts sitting here in Oakland. We rely upon internal expertise, and with a pool of 10,000 physicians, you can imagine the expertise that we have in almost every area. So if you're a physician in Atlanta, you'll find that the things coming out of CMI are credible because last month or last year you participated in a CMI work group creating the new asthma guidelines for all of Kaiser Permanente.

MC: How does that work? We'll take asthma for example. You identify the Kaiser physicians who deal with it the most?

MC: What role do practice guidelines play in this whole process?

JUHN: Potentially a very good one. I say potentially because "guidelines" is one of those terms that's so overused that the original meaning is lost. There's a spectrum in the use of guidelines. Some so-called guidelines are very restrictive: "Thou shalt use this guideline to treat this patient." The other extreme is to say that guidelines are really guides. A guideline is a set of knowledge or information to help inform you to make the right decision. It's much more of an aid as opposed to a mandate.

MC: Do you think there's a distinction in how guidelines are employed, that some plans don't treat them as guidelines, but as mandates?

JUHN: Exactly. At many for-profit plans, there's a mixed message in some of those guidelines and there are some inherent conflicts of interest.

MC: So you think it is a fair statement that some guidelines are not clinically justified?

JUHN: Exactly. Now I don't want to cast dispersions on for-profit plans, because part of the pressure they're feeling is from purchasers. It's been interesting that the one group that has gone unnoticed and unscathed in all the bashing of managed care is the purchasers. It's the purchasers who contribute the dollars to determine what's going to be covered and what's not going to be covered. When you have fewer dollars going into the system, more demands on the system, and for-profit companies who have shareholders to satisfy, you get into a situation where guidelines can conflict. There can be some subtle, and sometimes not-so-subtle, conflicts of interest.

MC: Someone at a for-profit plan might point out that Kaiser Permanente has had some financial problems lately, so who's to say that those same conflicts don't exist there?

JUHN: In certain ways, there's some fairness to that question. We have had financial troubles but I also think that our approach is somewhat different. There are two world views right now of how to address health care costs. One approach is to wring out as much cost as we can, and get close to that line where you might be actually jeopardizing people's health. In the other world, cost reduction and quality are not necessarily trade-offs. We believe, with the appropriate health conditions, that if we make the right up-front investment in systems of care, and the right interventions with individual patients, that those investments will, over time, lead to payoffs and lower costs.

MC: For example?

JUHN: An easy one is diabetes. Diabetes is not as expensive a disease from a daily treatment standpoint. Diabetes becomes expensive when a person develops the three big complications: blindness, renal failure leading to dialysis or transplantation, or peripheral neuropathy leading to amputation. All three of those are bad for the patient, whose functional status deteriorates drastically, and are very costly for whoever has to foot the bill. In diabetes, interventions up front that are quite modest in cost, like better treatment and better management of blood sugars, will have significant downstream effect. Like they said in TV ads for oil filters: "You can pay me now, or pay me later."

MC: At what point do you go back to those five and see how current you are?

JUHN: On a quarterly basis.

MC: Ultimately how many sets of guidelines do you expect that you'll have?

JUHN: Let me make a distinction between a guideline and a care-management program. A care-management program is the A-Z, soup-to-nuts group of things that you need to manage a group of diabetics, for example. Our diabetes care-management program has about twenty different guidelines, but those guidelines are in addition to patient education materials, information systems, software programs and the patient record-tracking system. The last piece is having a model of care that sets out how you organize the diabetes clinic. So that's what we mean by care management. It's not a guideline on diabetes. It's a compendium of knowledge that's directed at the patient, the provider and the administrator to actually have a system of care.

MC: To what degree does this approach increase the use of nonphysician providers?

JUHN: Quite a bit, in the sense that there's a realization that nonphysician providers, and it's hard to use that term cause there's not any other good term ...

JUHN: If you want to be nailed on the head, call someone a physician extender. There are two realizations that are going on in health systems right now. One is that an organized team approach to care is more effective than a one-on-one encounter, especially for a complex disease. Realization 2 — and this is a hard one for physicians — is that they're not the best at doing everything in health delivery. There are some people who are much better at talking to the patient, or at tracking down lab tests and what not. So there's a recognition that nurses, nurse practitioners, nutritionists, podiatrists, physician assistants, all have a certain expertise that can complement what a physician does and not necessarily substitute for a physician.

MC: How big a challenge is it persuading physicians of the wisdom of that approach?

JUHN: It's been hard, but it's going to get easier because of economics. There's less money in the system and more physicians, so if you don't like our system go get another job.

MC: You mentioned purchasers. They like to tout efforts to improve quality through such things as HEDIS and the use of health plan report cards. How seriously do you take those efforts?

JUHN: You should go ask the purchasers, "The last time you negotiated an agreement with a health plan, how important a factor was quality?" It's lucky if quality is one of the top five reasons for choosing a health plan. Another way of saying this is that at least 80 percent of their decision was predicated upon price.

MC: Does it make sense to have purchasers playing a central role, or is it a question that doesn't merit being asked because it's not going to change any time soon?

JUHN: No, it's going to change, partly because right now the individual physician's wrath is almost misdirected. It's directed at health plans, when it should be directed at the federal government or certain companies that are unwilling to pay more for health care. Consumers' complaints also are misdirected. They're complaining to or about individual physicians, who are feeling this pressure from health plans. Or consumers complain about big bad managed care when, if I'm a Company X employee and I feel that my care is substandard, I should be interested in what my benefits department at Company X has done about providing better suppliers of health care to me. It might be worthwhile to find out the hidden but incredibly influential and powerful role that purchasers are currently playing.

MC: How valuable is HEDIS?

JUHN: It depends on which perspective you take. From a purchaser perspective it's the closest thing you have to something like Consumer Reports that looks at quality on a comparative basis. From an internal perspective, for me as an internist wanting to improve the care that I deliver to my patients, HEDIS numbers are almost meaningless because they don't have any direct relevance to what I'm doing.

MC: What's going to change the system?

JUHN: More and more pressure from individual providers. They're going to eventually get wise and say, "Hey, it's not the health plan we should worry about. It's, 'Why are we helping the shareholders at Company X get rich by reducing their health insurance bills?'" We're in an interesting transition in health care. We're moving from a world that was characterized very much by a provider-centric view back in the glory years of medicine. The physician was in charge of the system and everything revolved around him or her. The ultimate destination is the patient-centric world. Right now in this transition, we're in a purchaser-centric world, where purchasers, because of their clout, are really dictating to providers and to patients. They're telling providers that they're not going to pay more for health care and that they're going to have to do with limited resources. Purchasers' message to their employees is that ten years ago you could go anywhere because you had a fee-for-service card. Five years ago you had a choice of maybe four or five health plans. Next year, you'll have a choice of one. On the consumer side, you're going to see more concerns raised by people asking about the role of the person who ultimately pays for health care, their employers.

MC: What is the role that care management plays in helping to alleviate those pressures?

JUHN: Those pressures are mostly financial. Care management is on a different playing field.

MC: Is it?

JUHN: Yes, I think so. Of course there's a financial link and obviously part of care management is bringing science and technology to the point of care to promote better decisions and better judgment by both providers and patients.

MC: Let's face it, if you were to tell Kaiser's board of directors or large purchasers that you're developing an approach called care management that will cost a lot more money but will make for healthier people down the road, that would be a non-starter.

JUHN: It's a tricky one. The model that we're trying to follow at Kaiser Permanente is investing in quality and then achieving the cost returns over time.

MC: Which in this country is a hard sell, as is anything that requires an up-front investment for a long-term benefit.

JUHN: This is actually why Kaiser Permanente is one of the few organizations that can actually embark on a strategy like this, because we have a large membership that is actually quite stable, despite what you hear. In fact it's been growing, in part because our rates have been competitive and we've been attracting lots of members. But if you look at the so-called voluntary turnover within a health plan like Kaiser Permanente it's very low. We know that people who join Kaiser Permanente are going to be with us for a long time unless they move out of state or their employer switches health plans.

MC: It seems like that turnover is a problem with some of the for-profit plans.

JUHN: Very much, because the for-profit plans are in the transaction business. They're like the Wall Street folks, whether they buy or sell they make money.

MC: Plans have been known to come into a market with a very low premium to build market share and then jack up premiums, so everybody jumps ship.

JUHN: [Laughing.] And they want them to jump ship. There's this approach that borders on unethical that is quite damaging.

MC: What would constitute success for the Care Management Institute?

JUHN: When there is a cultural shift in how physicians view their work.

MC: A shift from what to what?

JUHN: From this Lone Ranger notion that "I'm out here on my own, I need to keep up with the evidence and literature, and I'm going to do what I think is best for the patient." That's giving way to the notion that this is a very complex enterprise. "I need to work together with my colleagues and rely upon my colleagues in some cases to present to me the evidence and the literature to do the right things for my patients." This will have hopefully three very tangible and physical effects. Patients' functional status and outcomes will improve. There will be greater efficiencies within health delivery, i.e. there will be positive changes in the cost structure. There will be greater satisfaction with the delivery systems among patients and providers.

MC: What about small groups that are not part of a large system of care like Kaiser? Is this something that can work for them as well?

JUHN: It could but it would be hard, because they just can't afford a CMI. We're part of an overhead that's distributed among $15 billion worth of revenue. So it's hard for much smaller plans to make this investment.

MC: Is it your sense that the other large non-profit health plans are doing work that is similar to CMI?

JUHN: Yes, there are. Harvard Pilgrim up in the Northeast, Group Health Cooperative of Puget Sound, which is affiliated with Kaiser. There are other smaller ones but the smaller ones are having trouble because, quite honestly, I don't think they can afford his approach.